Form 1.1 HIV

Evaluation of Risk Factors Associated with HIV, HBV and HCV in Chinese Donors (NHLBI)

Attachment 1 1_HIV Qx

HIV Risk Factor

OMB: 0925-0596

Document [doc]
Download: doc | pdf

Attachment 1.1

OMB No. (0925-xxxx), Expiration Date (xx/xx/xxxx)



RETROVIRUS EPIDEMIOLOGY DONOR STUDY-II (REDS-II)

HIV RISK FACTOR QUESTIONNAIRE



Thank you for taking the time to help us with this important study. Participation in this study is entirely voluntary. You may refuse to participate now, or at any time during the process. Refusal to participate in the study or withdrawing from the study will involve no penalty.


You do not have to answer any questions you do not wish to, and you may stop at any time. You may refuse to answer any question(s) that make(s) you feel uncomfortable or upset(s) you.





Date: __ __/__ __/__ __ __ __ (D D/ M M / Y Y Y Y)


Study identification number: __ - __ __ __ __ __ __ __ - __


  1. When were you born?


19__ __ (year)

  1. What is your gender?


1 Female

2 Male

  1. What is your place of birth?


___________ ______________
City/county Province

  1. What is your ethnicity?

1 Han

2 Hui

3 Uygur

4 Man

5 Dai

6 Other, specify ______________

  1. What is your current occupation?

1 Worker

2 Farmer

3 Business

4 Service

5 Education/research/government

6 Military/Police

7 Medicine/Health care

8 Student

9 Other, specify _____________

6. What is the highest level of education you have received?

1 Primary school or less

2 Junior high school

3 High School or vocational school

4 Bachelor’s degree

5 Graduate level degree

6 Other, specify _____________

7. What is your marital status?

1 Never married

2 Married

3 Divorced

4 Separated

5 Widowed

6 Other, specify _____________

8. How many times have you donated blood?


a. Year and type of each blood donation (If you have donated blood more then 4 times, please list the most recent three)

__ __ time (s)


1. __ __ __ __ (year)

Donation type: Whole blood donation

Apheresis donation

2. __ __ __ __ (year)

Donation type: Whole blood donation

Apheresis donation

3. __ __ __ __ (year)

Donation type: Whole blood donation

Apheresis donation

9. How much do you agree or disagree about phrases below:

    1. It’s important that I received blood test results from blood donation.




    1. I think blood donation is a good, fast, anonymous way to get my blood test.




    1. One of my reasons for donating blood is to find out if I have HIV and/or hepatitis infection.


1 Do not agree at all

2 Disagree a little

3 Agree a little

4 Agree very much


1 Do not agree at all

2 Disagree a little

3 Agree a little

4 Agree very much


1 Do not agree at all

2 Disagree a little

3 Agree a little

4 Agree very much

10. Have you ever received acupuncture treatment?




a. In the 12 months before your most recent donation, did you have acupuncture?

1 Yes ANSWER QUESTION a

2 No SKIP TO 11

99 Unknown SKIP TO 11


1 Yes

2 No

99 Unknown

11. In the 12 months before your most recent donation, did you have any injection (including intravenous and intramuscle injections)?


a. How many times did you have injection(s)?

1 Yes ANSWER QUESTION a

2 No SKIP TO 12

99 Unknown SKIP TO 12


__ __ times

12. Have you had any finger sticks?




a. In the 12 months before your most recent donation, did you have finger sticks?

1 Yes ANSWER QUESTION a

2 No SKIP TO 13

99 Unknown SKIP TO 13


1 Yes

2 No

99 Unknown

13. Have you ever had in-patient medical surgery?



a. In the 12 months before your most recent donation, did you have in-patient medical surgery?

1 Yes ANSWER QUESTION a

2 No SKIP TO 14

99 Unknown SKIP TO 14


1 Yes

2 No

99 Unknown

14. Have you ever had out-patient medical surgery?




a. In the 12 months before your most recent donation, did you have out-patient medical surgery?

1 Yes ANSWER QUESTION a

2 No SKIP TO 15

99 Unknown SKIP TO 15


1 Yes

2 No

99 Unknown

15. Have you ever had cosmetic surgery (e.g. laser, eye/lip surgery, collagen injection, dermal abrasion)?



a. In the 12 months before your most recent donation, did you have cosmetic surgery?

1 Yes ANSWER QUESTION a

2 No SKIP TO 16

99 Unknown SKIP TO 16


1 Yes

2 No

99 Unknown

16. Have you ever received a blood transfusion?



a. How many times did you have blood transfusions?


b. Year of your first time of blood transfusion?


c. Year of your last time of blood transfusion?

1 Yes ANSWER a, b AND c

2 No SKIP TO 17

99 Unknown SKIP TO 17


__ __ times


__ __ __ __ (year)

__ __ __ __ (year)

  1. Have you ever had any dental cleaning?



a. In the 12 months before your most recent donation, did you have dental cleaning?

1 Yes ANSWER QUESTION a

2 No SKIP TO 18

99 Unknown SKIP TO 18


1 Yes

2 No

99 Unknown

  1. Have you ever had any dental surgery, such as root canal treatment or tooth extraction?



a. In the 12 months before your most recent donation, did you have dental surgeries?

1 Yes ANSWER QUESTION a

2 No SKIP TO 19

99 Unknown SKIP TO 19


1 Yes

2 No

99 Unknown

  1. Have you ever had any endoscopy (such as gastroscopy and colonoscopy)?


a. In the 12 months before your most recent donation, did you have endoscopies?

1 Yes ANSWER QUESTION a

2 No SKIP TO 20

99 Unknown SKIP TO 20


1 Yes

2 No

99 Unknown

20. When you had acupuncture, finger sticks, or injections, were needles and syringes used disposable?

1 Seldom

2 Sometimes

3 Often

4 Always

99 Unknown

21. Have you ever been told that you are at risk for spreading diseases through your blood?

1 Yes

2 No

99 Unknown

22. Have you ever been deferred as a blood donor?




a. For what reason were you deferred?

1 Yes ANSWER QUESTION a

2 No SKIP TO 23

99 Unknown SKIP TO 23


Specify ______________________

  1. Have you ever been previously diagnosed with hepatitis?



a. What type(s) of hepatitis did you have?

1 Yes ANSWER QUESTION a

2 No SKIP TO 24

99 Unknown SKIP TO 24


1 HAV

2 HBV

3 HCV

4 Other, specify _____________

99 Unknown

24. Have you ever been previously diagnosed with syphilis, gonorrhea, or any other sexually transmitted disease?


1 Yes

2 No

99 Unknown

25. Have any of your family members had hepatitis?

1 Yes

2 No

99 Unknown

26. Have any of your family members had HIV/AIDS?

1 Yes

2 No

99 Unknown

27. Have you ever had household contact with someone with hepatitis or HIV/AIDS?



a. In the 12 months before your most recent donation, did you have household contact with someone with hepatitis or HIV/AIDS?

1 Yes ANSWER QUESTION a

2 No SKIP TO 28

99 Unknown SKIP TO 28


1 Yes

2 No

99 Unknown

28. Have you ever used needles to shoot street drugs?




a. How long have you shot drugs?


b. How many times per month did you shoot drugs?


c. Have you ever shared needles or syringes with others to inject street drugs?

1 Yes ANSWER a, b AND c

2 No SKIP TO 29

99 Unknown SKIP TO 29


__ __ years


__ __ times/month


1 Yes

2 No

99 Unknown

29. Have you ever used illegal oral or intranasal drugs without doctor’s prescription?



a. In the 12 months before your most recent donation, did you use illegal oral or intranasal drugs without doctor’s prescription?

1 Yes ANSWER QUESTION a

2 No SKIP TO 30

99 Unknown SKIP TO 30


1 Yes

2 No

99 Unknown

30. Have you ever lived with a person with illegal injection?




a. In the 12 months before your most recent donation, did you live with a person with illegal injection?

1 Yes ANSWER QUESTION a

2 No SKIP TO 31

99 Unknown SKIP TO 31


1 Yes

2 No

99 Unknown

31. Are any of your close friends or family members intravenous drug users?

1 Yes

2 No

99 Unknown

32. Have you had 2 or more sexual partners of the opposite sex?



a. How many heterosexual partners did you have?





b. How often do you or your sex partner use a condom when you have sex with your heterosexual partner?

1 Yes ANSWER a AND b

2 No SKIP TO 33

99 Unknown SKIP TO 33


1 2-4

2 5-7

3 8-10

4 >10


1 Never

2 Sometimes

3 Half of time

4 Most of time

5 Always

33. (For male only) In your lifetime, have you ever had sex with another male?



a. How many times did you have sex with males?


b. How many male partners have you had sex with?


c. How often do you or your sex partner use a condom when you have sex with male partner?

1 Yes ANSWER a, b AND c

2 No SKIP TO 34

99 Unknown SKIP TO 34


__ __ times


__ __ partners


1 Never

2 Sometimes

3 Half of time

4 Most of time

5 Always

34. Have you ever paid or received money for having sex?




a. How many times have you paid or received money for having sex?


b. In the 12 months before your most recent donation, did you pay or receive money for having sex?

1 Yes ANSWER a AND b

2 No SKIP TO 35

99 Unknown SKIP TO 35


__ __ times



1 Yes

2 No

99 Unknown

35. Have you ever had a sex partner that was an intravenous drug user?



a. In the 12 months before your most recent donation, did you have a sex partner that was an intravenous drug user?

1 Yes ANSWER QUESTION a

2 No SKIP TO 36

99 Unknown SKIP TO 36


1 Yes

2 No

99 Unknown

36. In the past ten years, have you ever had a sex partner who had a positive test for syphilis, gonorrhea, or any other sexually transmitted disease?


a. In the 12 months before your last donation, did you have a sex partner who had a positive test for syphilis, gonorrhea, or any other sexually transmitted disease?

1 Yes ANSWER QUESTION a

2 No SKIP TO 37

99 Unknown SKIP TO 37


1 Yes

2 No

99 Unknown

37. In the past ten years, have you ever had a sex partner who had been diagnosed with hepatitis or HIV/AIDS?



a. In the 12 months before your most recent donation, did you have a sex partner who had been diagnosed with hepatitis or HIV/AIDS?

1 Yes ANSWER QUESTION a

2 No SKIP TO 38

99 Unknown SKIP TO 38


1 Yes

2 No

99 Unknown

38. In the past one year, have you had sexual contact with anyone who received blood transfusion?



a. In the 12 months before your most recent donation, did you have sexual contact with anyone who received blood transfusion?

1 Yes ANSWER QUESTION a

2 No SKIP TO 39

99 Unknown SKIP TO 39


1 Yes

2 No

99 Unknown

39. Have you ever contacted with human blood and other human body fluids in your workplace?



a. In the 12 months before your most recent donation, did you contact with human blood and other human body fluids in your workplace?

1 Yes ANSWER QUESTION a

2 No SKIP TO 40

99 Unknown SKIP TO 40


1 Yes

2 No

99 Unknown

40. Have you ever had a tattoo?




a. In the 12 months before your most recent donation, did you have a tattoo?

1 Yes ANSWER QUESTION a

2 No SKIP TO 41

99 Unknown SKIP TO 41


1 Yes

2 No

99 Unknown

41. Have you ever had your ears or other body parts pierced?



a. In the 12 months before your most recent donation, did you have your ears or other body parts pierced?

1 Yes ANSWER QUESTION a

2 No SKIP TO 42

99 Unknown SKIP TO 42


1 Yes

2 No

99 Unknown

42. Did you receive notification from blood center about your infection status?



a. Did you seek further testing or health care according to the instruction of the notification?


b. Are you planning to seek further testing or health care according to the instruction of the notification?

1 Yes ANSWER a AND b

2 No END

99 Unknown END


1 Yes END

2 No ANSWER QUESTION b

99 Unknown END


1 Yes

2 No

99 Unknown

Thank you very much for your participation!



10


File Typeapplication/msword
File TitleRETROVIRUS EPIDEMIOLOGY DONOR STUDY-II (REDS-II)
AuthorLing Shi
Last Modified Bycurriem
File Modified2008-10-22
File Created2008-10-22

© 2024 OMB.report | Privacy Policy